|
APPENDIX A
UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF MARYLAND |
| IN RE: |
Debtor(s) |
:
:
:
: |
|
Case No.
Chapter
Adversary proceeding No. |
F I N A N C I A L S T A T E M E N T
|
MONTHLY INCOME |
| GROSS: |
$ |
|
| LESS DEDUCTIONS: |
| Federal Tax |
|
| State Tax |
|
| FICA or Retirement |
|
| All other deductions |
|
|
|
|
|
| NET INCOME: |
$ |
|
| Income from
property |
|
|
| Income from any
other sources |
|
|
| Tax Refund |
|
|
| Monies from
spouse |
|
|
TOTAL MONIES
RECEIVED: |
|
|
| MONTHLY
EXPENSES: |
Party |
Children |
Expenses Now
Paid by Spouse |
| Rent |
|
|
|
| House Payment |
|
|
|
| Utilities: Heat Gas &
Light |
|
|
|
| Telephone |
|
|
|
| Food |
|
|
|
| Medical, Dental |
|
|
|
| Transportation |
|
|
|
Insurance: Life |
|
|
|
| Health |
|
|
|
| Auto |
|
|
|
| Other |
|
|
|
Child Care Expense |
|
|
|
| Recreation |
|
|
|
| Incidentals |
|
|
|
Periodic Pymts.
(attach list) |
|
|
|
| TOTAL
EXPENSES: |
|
|
|
| A S S E T S |
|
|
|
L I A B I L I T I E S |
|
|
|
$ |
|
|
|
$ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| TOTAL ASSETS: |
$ |
|
|
TOTAL LIABILITIES |
$ |
|
I HEREBY SWEAR OR AFFIRM UNDER THE PENALTIES OF PERJURY
THAT THE ABOVE FINANCIAL STATEMENT IS TRUE AND CORRECT.
________________________________________________________
(Party) (Date)
Local Bankruptcy Form D
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